Evolent Health Registered Nurse - Team Lead, Appeals and Grievances in Pensacola, Florida

We are currently seeking a Registered Nurse with experience in Appeals & Grievances to join us as a Team Lead due to tremendous growth!

Who are we? We are a dynamic health care organization who is on a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins.

Come join us!

What You’ll Be Doing:

  • Assist the manager in performing audits and monitoring consistency and quality of the team to measure compliance with regulatory and accreditation standards

  • Using subject matter expertise, prepare and deliver reports reflecting open cases, cases approaching timeliness, cases requiring escalation, closed case reporting, client reporting and other reports to manage the appeals and grievances function

  • Monitor productivity of Appeals and Grievance team to achieve timely, accurate and thorough resolution of A&G cases, meeting performance standards and compliance requirements

  • Supervise personnel to ensure a positive team environment, conduct performance reviews to provide feedback and development opportunities

  • Orient, train and mentor new team members alongside Manager

  • Communicate and partner with other departments, clients, vendors and stakeholders

  • Supervise and monitor daily workflow, assess workloads and adjust as necessary to ensure work is completed timely and in compliance

  • Perform other duties as assigned

The Experience You Need (Required):

  • RN License

  • 3 years of appeals and grievances experience in a payer-based environment

  • 3 years of supervisory or training experience

  • Expertise in Medicare Part C appeals and grievances regulatory requirements

  • Proficiency with PC-based software programs including Word, Excel and Outlook

  • Access to high speed broadband or DSL internet in a secure home office

  • Excellent written and oral communication skills

  • Ability to travel to client, vendors and other Evolent locations, approximately 20-35%

  • Ability to work remotely and independently

Finishing Touches (Preferred):

  • BS Degree or equivalent work experience

  • Experience with fully insured and self-funded LOB including Exchange and ERISA requirements

  • Experienced with CMS and other audits, preferably presenting cases to CMS and other entities

  • Medical or claims coding experience

  • Medical claims review experience

  • Experience with or knowledge of claims processing practices

  • Strong critical thinking, analytical, research and organizational skills

Evolent Health is an Equal Opportunity/Affirmative Action Employer